A nurse is caring for a 15-year-old adolescent who is admitted with a vaso-occlusive crisis in the emergency department.
Select the 5 interventions the nurse should include.
Apply cold compresses to the affected joints.
Administer meperidine IV for pain.
Administer folic acid as prescribed.
Restrict oral intake.
Give oral hydroxyurea.
Monitor oxygen saturation continuously.
Place the client on strict bed rest.
Instruct the parent to ensure the pneumococcal vaccine is current
Correct Answer : C,E,F,G,H
Choice A rationale: Applying cold compresses to the affected joints is not recommended for vaso-occlusive crises in sickle cell disease. Cold can cause vasoconstriction, which may worsen the pain and decrease blood flow to the affected areas. Warm compresses are preferred to promote vasodilation and improve blood flow.
Choice B rationale: Administering meperidine IV for pain is not recommended due to the risk of neurotoxicity and the potential for seizures with repeated use. Other opioids, such as morphine or hydromorphone, are preferred for managing severe pain in vaso-occlusive crises.
Choice C rationale: Administering folic acid as prescribed is important for clients with sickle cell disease. Folic acid helps in the production of new red blood cells, which is crucial for individuals with sickle cell disease who experience chronic hemolysis and anemia.
Choice D rationale: Restricting oral intake is not necessary for a client with a vaso-occlusive crisis unless there are specific medical indications. Adequate hydration is essential to help reduce the viscosity of the blood and prevent further sickling of red blood cells.
Choice E rationale: Giving oral hydroxyurea is important for managing sickle cell disease. Hydroxyurea helps to increase the production of fetal hemoglobin, which reduces the frequency and severity of vaso-occlusive crises. It is a key medication in the long-term management of sickle cell disease.
Choice F rationale: Monitoring oxygen saturation continuously is important to ensure that the client is receiving adequate oxygenation. Hypoxia can exacerbate sickling of red blood cells and worsen the vaso-occlusive crisis. Continuous monitoring allows for prompt intervention if oxygen levels drop.
Choice G rationale: Placing the client on strict bed rest is important to reduce metabolic demands and prevent further pain and complications. Rest helps to conserve energy and reduce the risk of additional stress on the body during a vaso- occlusive crisis.
Choice H rationale: Instructing the parent to ensure the pneumococcal vaccine is current is important for preventing infections. Clients with sickle cell disease are at increased risk for infections, particularly with encapsulated bacteria like Streptococcus pneumoniae. Keeping vaccinations up to date is crucial for reducing the risk of serious infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Increasing fluid intake is not appropriate as it does not address the issue of vomiting and can lead to fluid overload.
Choice B rationale
Giving an antiemetic is not recommended without consulting a healthcare provider as it may interact with digoxin.
Choice C rationale
Administering the next dose as prescribed is the correct action. If a dose is vomited, it should not be repeated, and the next dose should be given at the regular time.
Choice D rationale
Mixing the medication with 8 oz of formula is not recommended as it can affect the absorption and effectiveness of the medication.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Ensuring that all patients are moved out of harm’s way is the first priority in a nursing home fire situation. This action aligns with the principles of the ABCs of nursing prioritization, where ensuring safety and preventing harm is paramount.
Choice B rationale
Removing all flammable materials from the area and extinguishing the fire is important, but it comes after ensuring the safety of the patients. The primary focus should be on patient safety.
Choice C rationale
Reporting to the area of the fire and taking measures to extinguish and/or contain it, if possible, is a secondary action. The immediate priority is to ensure the safety of the patients.
Choice D rationale
Evacuating all patients from the building immediately is not always feasible or safe. The priority is to move patients out of immediate harm’s way and then proceed with further evacuation if necessary.
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